Executive Editor: Peter Trafton

Authors: Martin Jaeger, Frankie Leung, Wilson Li

Proximal humerus Extraarticular 2-part, surgical neck, impaction

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Glossary

General considerations

These fractures are intrinsically stable due to the metaphyseal impaction and respond well to gentle early mobilization. The decision for operative management should depend on the degree of fracture deformity (angulation). Mild-moderate angulation is well tolerated. Significant deformity may require reduction and fixation. The main aim of treatment is to achieve fracture union with acceptable alignment, with little functional impairment.

The functional demands of the patient, the presence of comorbidities, and risk of delayed fracture displacement should be considered. Nonoperative treatment usually achieves good results, particularly for varus impacted fractures.

Nonoperative
Main indication Skill Equipment
Acceptable deformity Basic surgical experience, no specialized skills Basic equipment only

Supporting indications

  • Risks of surgery outweigh benefits
  • Varus impacted fractures

Advantages

  • No operative risks
  • No anesthetic risks

Disadvantages

  • Risk of displacement
  • Initially limited use
MIO - Screw fixation
Main indication Skill Equipment
Unacceptable deformity and/or risk of displacement Some specialized surgical experience Full specialized surgical and imaging resources

Supporting indications

  • Good bone quality
  • Unacceptable deformity
  • Need for more stability and/or earlier mobilization

Advantages

  • Minimal soft-tissue damage

Disadvantages

  • Disimpaction causes instability, which fixation must overcome
  • Stability of screw fixation may be limited
  • No exposure for reduction
  • Risk of damage to the axillary nerve
MIO - Plate fixation
Main indication Skill Equipment
Unacceptable deformity and/or risk of displacement Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Supporting indications

  • Good bone quality
  • Unacceptable deformity
  • Need for more stability and/or earlier mobilization

Advantages

  • Better stability than screws alone
  • Less soft-tissue damage than ORIF
  • Possibility of earlier motion

Disadvantages

  • Disimpaction causes instability, which fixation must overcome
  • Reduction may be difficult
  • Risk of damage to the axillary nerve
Nailing (straight nail)
Main indication Skill Equipment
Unacceptable deformity and/or risk of displacement Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Supporting indications

  • Unacceptable deformity
  • Need for more stability and/or earlier mobilization

Advantages

  • Strong fixation in poor bone quality
  • Entrance point of the nail does not interfere with the footprint of the supraspinatus tendon
  • Less extensive exposure than ORIF
  • Possibility of earlier motion

Disadvantages

  • Possible increased shoulder pain, or rotator cuff disturbance
  • Reduction may be difficult
  • Risk of damage to the axillary nerve
  • Violation of the rotator cuff
Nailing (bent nail)
Main indication Skill Equipment
Unacceptable deformity and/or risk of displacement Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Supporting indications

  • Good bone quality
  • Unacceptable deformity
  • Need for more stability and/or earlier mobilization

Advantages

  • Less extensive exposure than ORIF
  • Possibility of earlier motion

Disadvantages

  • Possible increased shoulder pain, or rotator cuff disturbance
  • No hardware fixation of lesser tuberosity
  • Entry point of the nail may interfere with the footprint of the supraspinatus tendon and/or with the fracture line of the greater tuberosity if present
  • Reduction may be difficult
  • Risk of damage to the axillary nerve
  • Violation of the rotator cuff
ORIF - Screw fixation
Main indication Skill Equipment
Unacceptable deformity and/or instability Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Supporting indications

  • Unacceptable deformity
  • Need for more stability and/or earlier mobilization
  • Bone quality and fracture pattern suitable for fixation with screws alone

Advantages

  • Less retained hardware, may protect vascularity
  • Earlier mobilization might be achievable under favorable circumstances

Disadvantages

  • Disimpaction causes instability, which fixation must overcome
  • Risk of secondary loss of reduction, possibly greater than with angular stable plate
ORIF - Plate fixation
Main indication Skill Equipment
Unacceptable deformity and/or instability Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Open reduction and angular stable plate osteosynthesis, if available, is the currently favored technique for these fractures.

Supporting indications

  • Unacceptable deformity
  • Need for more stability and/or earlier mobilization
  • Osteoporotic bone

Advantages

  • Earlier mobilization
  • No violation of the rotator cuff
  • Currently most stable fixation

Disadvantages

  • Technically demanding
  • Reduction must be nearly anatomical
  • Disimpaction causes instability, which fixation must overcome
Reverse arthroplasty
Main indication Skill Equipment
Displaced fractures in elderly patients Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Supporting indications

  • Comminuted fractures of the tuberosities and/or small fragments of the tuberosities such as avulsion or impression fractures
  • Proximal humeral fractures with a preexisting rotator cuff tear

Advantages

  • Shoulder function less dependent on healing of the tuberosities
  • Predictable satisfactory outcome in relation to pain relief and shoulder function
  • One-step procedure

Disadvantages

  • Special experience of the surgeon necessary
  • Minimal revision options if surgery fails
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v2.0 2011-05-02